NMC’s Principles for supporting women’s choices in maternity care

The NMC have recently published Principles for supporting women’s choices in maternity care.
They aim to drive ‘safer, more person-centred care for women and babies’ when maternity care is

• declined (‘freebirthing’)
• requested ‘outside of guidance’,
• involves ‘unregulated people’ such as doulas and other birthworkers

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At first glance, I thought it was a very positive guide, which could help midwives and employers feel more relaxed and confident in accommodate a range of birth choices that they might otherwise be uncomfortable with or threatened by.
It starts off with reference to (unspecified) legislations which ‘supports the autonomy and agency of women to choose where they wish to give birth, who they wish to have with them and whether they choose some or no midwifery or medical input’
The positive points that stand out for me are –

Women using maternity services should expect to:

• Have a personalised care and support plan that reflects and respects their views, preferences and decisions, including where care is declined and does not require them to justify their decision
• Be able to decline or stop conversations around their care, regardless of their reason to do so
• Receive personalised care, ideally with continuity of care and carer, as an important element of an ongoing, supportive relationship

The role of the midwife includes:

• Be ‘professionally curious’ and seek to recognise and understand the reasons why women choose to freebirth or birth ‘outside of guidance’
• ‘Respect and work in partnership with the woman in a non-coercive manner to explore options’ ( – Much of this focus on respectful care and informed choice is nothing new – it reflects the NMC Code and NMC Standards of Proficiency for Midwives (2019) which includes ‘respecting the woman’s right to decline consent’ – but the introduction of the term ‘non-coercive’ suggests an acknowledgement that in some circumstances women and birthing people have experienced coercive care.)
• ‘Emphasise to women opting out of midwifery care that they can resume the care whenever they choose, without judgement or prejudice; in such cases, ensure that the woman knows how and who to contact about this’
  ( – This is really important practical guidance & acknowledges the fear of those declining recommended care that they may risk lose their right to that care in future if circumstance or their preference change.)
• ‘Be aware … a freebirth does not constitute a safeguarding concern unless there is a formally diagnosed lack of capacity … or other issues such as domestic abuse’

However, on closer inspection there are also some troubling elements.

It is concerning that although women should ‘have a personalised care and support plan’ which the midwife develops ‘in partnership with the woman’– the midwife should ‘respect the woman’s decision’ but not necessarily do all they can to implement it. Neither are employers expected to implement the wishes of the woman or birthing person. This seems like a step backwards from the Standards for Proficiency which state that a midwife will be able to: (6.64) ‘effectively implement, review, and adapt an individualised, evidence informed care plan’. But maybe that referred to a care plan written by colleagues, not the birthing person?

There is inconsistency in the wording around conversations. The birthing person should be able to ‘decline or stop conversations’ around their choices – but this is then undermined by the requirement for a midwife to ‘promote evidence-based discussions with the woman’ and ‘discuss and give a clear rationale for alternative care pathways’. More consistent wording might have been for the midwife to ‘encouarge’ or ‘offer’ these important discussions.

There is further inconsistency between the midwife’s role to ‘emphasise to women opting out of midwifery care that they can resume the care whenever they choose, without judgement or prejudice – while employers are expected to ‘for a known freebirth, be clear prior to labour about whether or not a midwife will attend if called’.

The section on employers is even more disappointing. They are expected to ‘explore the available options’, ‘engage constructively’, ‘consider’ every request and ‘assess the feasibility’ of some requests – but employers are only expected to EXPLORE ‘how their rights COULD be upheld’, rather than ensuring their rights are upheld. They are expected to explore ‘the full range of available choices’ – but who decides what choices should or can be made available?

Employers are expected to ‘ensure that infrastructure and support systems are in place for midwives to provide safe care’ – how are systems that provide safe care defined, and are employers even in a realistic position to ‘ensure’ they are in place? Does this mean the NMC are expecting trusts to ‘ensure’ continuity of midwifery care?

There is further practical guidance for employers on how to manage when a care option might be temporarily unavailable due to service pressures. This normalises the practice of closing homebirth services or ’out of guidance’ support in these situations, with no guidance on how to decide which services can justifiably be suspended, devaluing these services by assuming they will be ‘the first to go’, often before consideration of postponing inductions and planned caesarean births.

The publication fails in its aim to explain ‘the distinct roles and responsibilities of midwives and doulas’. It does not explore the legal interpretation of the phrase ‘attend a woman in childbirth’ and fails to explain what counts as a ‘clinical role’ which doulas should not take on. Which parts of a midwife’s role are clinical and non-clinical? Is the emotional support midwives provide part of our clinical role? This really needs more clarity.

The principles have been developed in collaboration with a wide range of interdisciplinary and multiagency key stakeholders – it would be useful (and respectful) to acknowledge who those different stakeholders were, and how the ‘views of women across the UK’ were gathered. Perhaps this ‘coproduction’ explains why the principles are sometimes inconsistent and a bit vague – because they have been shaped by input from people or organisations with very different agendas and understandings.

Lastly I would have liked to see some reference from the NMC to the need for trauma-informed training (pre- and post-registration), including lived experience narratives, so that midwives and managers have the knowledge and skills to follow these principles in practice, to enable them to discuss the evidence-based information for different options and to facilitate a sometimes difficult decision-making process in a clear, accessible and non-coercive way. This needs an understanding of the power inequalities between users and health care providers, which sometimes results in maternity services being experienced as ‘coercive’. Coercion is usually denied by the perpetrator. Even caring midwives and doctors whose intention is to support informed choice can be coercive, mostly unknowingly. It will take more than the publication of these principles to address this issue.